Healthcare Provider Details

I. General information

NPI: 1598339616
Provider Name (Legal Business Name): LISA GUZMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E LAKEWOOD AVE
NORTHLAKE IL
60164-2592
US

IV. Provider business mailing address

301 VETERANS PKWY
NEW LENOX IL
60451-2899
US

V. Phone/Fax

Practice location:
  • Phone: 312-702-1381
  • Fax:
Mailing address:
  • Phone: 815-485-6197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.015762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: